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 Health Policy

The changing health needs of the UK population

Martin McKee*, Karen Dunnell*, Michael Anderson, Carol Brayne, Anita Charlesworth, Charlotte Johnston-Webber, Martin Knapp,
Alistair McGuire, John N Newton, David Taylor, Richard G Watt

The demographics of the UK population are changing and so is the need for health care. In this Health Policy, we Lancet 2021; 397: 1979–91
explore the current health of the population, the changing health needs, and future threats to health. Relative to other Published Online
high-income countries, the UK is lagging on many health outcomes, such as life expectancy and infant mortality, and May 6, 2021
[Link]
there is a growing burden of mental illness. Successes exist, such as the striking improvements in oral health, but
S0140-6736(21)00229-4
inequalities in health persist as well. The growth of the ageing population relative to the working-age population, the
See The Lancet Commissions
rise of multimorbidity, and persistent health inequalities, particularly for preventable illness, are all issues that the page 1915
National Health Service (NHS) will face in the years to come. Meeting the challenges of the future will require an *Joint lead authors
increased focus on health promotion and disease prevention, involving a more concerted effort to understand and †Dame Dunnell retired in
tackle the multiple social, environmental, and economic factors that lie at the heart of health inequalities. The August, 2009
immediate priority of the NHS will be to mitigate the wider and long-term health consequences of the COVID-19 Department of Health Services
pandemic, but it must also strengthen its resilience to reduce the impact of other threats to health, such as the UK Research and Policy, London
leaving the EU, climate change, and antimicrobial resistance. School of Hygiene & Tropical
Medicine, London, UK
(Prof M McKee MD); The Health
Introduction such as the Royal Colleges, emphasise maintaining high Foundation, London, UK
The UK’s National Health Service (NHS) has adapted standards of training and research rather than negotiating (Prof A Charlesworth MSc);
over time to many changing health needs and to advances terms and conditions, as is the case with some of their London, UK (K Dunnel BSc†);
Department of Health Policy,
in the technical and organisational ability to address equivalents elsewhere. However, some would argue that London School of Economics
them. These changing health needs include major progress has been slow and inadequate in adapting to and Political Science, London,
declines in infectious diseases and their evolving nature, epidemiological transition (eg, in mental health and the UK (M Anderson MSc,
as well as the rising importance of non-communicable rise in dementia) and in adopting research and innovation C Johnston-Webber MSc,
Prof M Knapp PhD,
diseases. Paediatric wards are no longer full of children at pace (eg, for stroke management). More recently, Prof A McGuire PhD); Cambridge
with gastroenteritis, respiratory infections, and hepatitis designated funding for health services research has Public Health, University of
A. Instead, these wards now provide specialised neonatal, helped build capacity enormously, relative to what exists Cambridge, Cambridge, UK
genetic, and chronic disease services, among others.1 in many other countries, but there remain many gaps in (Prof C Brayne MD); College of
Social Sciences, Health Services
Innovations in the management of mental health and the evidence base. A culture of evaluation and audit has Management Centre,
the resulting reconfiguration of services, such as the been promoted and has developed extensively in certain University of Birmingham,
closure of long-stay institutions, have completely altered areas, especially in areas supported by systematic national Birmingham, UK
treatment pathways, with both positive and negative data collection—eg, within the national clinical audit (Prof A Charlesworth); Public
Health England, London, UK
results. Cardiothoracic surgeons nowadays rarely dilate programme. This research capacity is now needed to (Prof J N Newton FRCP); UCL
mitral valves damaged by rheumatic heart disease or understand and develop strategies to mitigate the School of Pharmacy
resect tuberculous lung cavities; these days, they repair potentially long-lasting physical and mental health (Prof D Taylor BSc) and
Department of Epidemiology
congenital heart disease or do transplants. Orthopaedic impacts of the COVID-19 pandemic.6
and Public Health
surgeons no longer transplant tendons of children The goals of a health system were set out in the World (Prof R G Watt PhD), University
affected by polio, they instead replace arthritic joints Health Report in 2000.7 They include improving health College London, London, UK
among older people.2 General practitioners rarely deliver outcomes, responding to legitimate public expectations, Correspondence to:
babies in patients’ homes but instead contribute clinical and achieving fair financing. The third of these is Dr Michael Anderson,
expertise to a range of services provided by multi-agency addressed elsewhere in the Commission report. The first Department of Health Policy,
London School of Economics
teams based in the community. Dentists very rarely and second require an NHS that is cognisant of the and Political Science,
provide full dentures for adults and instead concentrate changing needs of the population and can adapt quickly London WC2A 2AE, UK
on prevention and provision of restorative care, including and flexibly to them, on the basis of evidence; when m.anderson5@[Link]
implants and bridges.3 Entirely new clinical careers and evidence is not available, the NHS should take steps to For more on the national clinic
specialties have emerged, such as specialist nurses, generate it. Subsequent thinking, developed more fully in audit programme see
[Link]
interventional radiologists, and palliative care specialists, the WHO Tallinn Charter,8 describes mutual relationships nca/#.XSxOXuhKhPZ
while geriatricians, managing the complex needs of frail between health systems, population health, and economic
and ageing patients, work alongside a growing number growth.9 Put simply, the goal of society should be to create
of superspecialists.4 a health system that promotes better health and, through
International comparative studies, particularly in earlier improved lives, secures economic growth, which in turn
decades, indicate that the NHS has been relatively good at secures revenues to support appropriate health-care
such adaptations.5 Its system of funding manages to avoid provision for all, as well as associated developments
many perverse incentives seen in fee-for-service systems elsewhere, such as in social care. Health and health care
that encourage lucrative interventions to persist long after can therefore be both inputs to and outputs from the
they have become obsolete, and professional associations, economy.

[Link] Vol 397 May 22, 2021 1979

 Health Policy

Yet, although it seems obvious that a key objective of tackle the social determinants of health. Finally, looking
the NHS should be to maximise the health of the UK ahead, we examine in the concluding section two
population to the extent that this is possible for a health immediate threats to the NHS: the COVID-19 pandemic
system to achieve, this interpretation has not always been and leaving the EU.
shared by its leadership. The mission of the NHS has, in
the past, been framed as the more limited, but potentially The health of the population
more tractable, objective of ensuring the provision of Life expectancy in the UK
high-quality and safe health care to all in response The health of the UK population is now lagging behind
to expressed need within available resources. This that of many comparable countries. Having been in the
longstanding mismatch between the need for a service middle of the range of high-income countries in 1960,
For more on life expectancy that optimises population health and a structure focused life expectancy at birth is now close to the bottom
data for the UK see [Link] predominantly on health-care provision only might well (figure 1). Since 2010, the rate of increase in life
[Link]/els/health-systems/
have contributed to the UK’s relatively poor performance expectancy at birth has slowed markedly.10 A 2019 analysis
[Link]
on health outcomes. compared life expectancy in England and Wales with
It is impossible, in a single paper, to provide a that in 22 other high-income countries,11 and showed
comprehensive analysis of the health of the UK population how England and Wales diverged markedly from the
and its implications for the NHS. Consequently, it has comparator group between 2011 and 2016. This
been necessary to be somewhat selective. This paper divergence was driven to a similar extent by diverging
proceeds as follows. We begin with an assessment of the mortality in people of working age and older people.
current situation and how it has developed, starting with Although more recent data are lacking for some
the most widely used summary measure of the health of comparator countries, the situation in the UK now gives
the population: life expectancy. We then review some substantial cause for concern; there have been continuing
areas that have important implications for the NHS. increases in death rates in several age groups and
These areas are mental health, maternal and child health, regions, and the infant mortality rate in England and
oral health (an area that has long existed on the margins of Wales rose each year in 2014–17, something that has not
the NHS), and the growing challenge of multimorbidity, happened for more than a century.12
with major implications for models of service delivery. The reasons why the UK is falling behind other
Further on, we look at three ways in which the health of high-income countries have been debated intensely.
the population is still changing: ageing, the composition Some of the decline probably reflects historical trends,
of the working population, and the burden of disease. such as the timing of the smoking epidemic,11 but there
The NHS is, in many respects, responding to failures in is increasing evidence pointing to a link with the wide-
other areas of policy. Consequently, in a third section, we ranging austerity measures since 2010 that have affected
examine the scope for prevention, including measures to many areas of public policy. For example, although the
explanation for rising infant mortality is disputed, it has
been noted that the increase is greatest in the poorest
Austria Belgium Canada Denmark Finland
France Germany Greece Ireland Italy areas.13 There have been substantial cuts to funding for
Japan Luxembourg Netherlands Portugal Spain local authorities, with resulting social care service
Sweden UK USA
85
reductions that particularly affect older people and those
living in poverty.14,15 An exceptional surge in numbers of
84 deaths in 2015 also coincided with widespread capacity
problems across the NHS and, although the particular
83
strain of influenza circulating that year might have
82 played a role, influenza seems unlikely to have been the
Life expectancy at birth (years)

only reason for this particular spike in mortality.16 A

81
further spike occurred in 2018. Importantly, although the
80 slowing is not unique and has been seen in some but not
all European countries, it has been more pronounced in
79 the UK than elsewhere, and it is not a survival asymptote
78
of maximum life expectancy being reached, as the UK
has not achieved the same levels as other comparable
77 high-income countries. Within the UK, when measured
by geography or socioeconomic indicators, it is apparent
76
that there is much scope for the health of the most
75 disadvantaged to improve substantially in terms of
1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018
healthy and disability-free life expectancy. Although
Figure 1: Trends in life expectancy at birth in the UK and comparable high-income countries differences in life expectancy between the richest and
Source: Organisation for Economic Co-operation and Development. poorest people in the UK narrowed during the 2000s,

1980 [Link] Vol 397 May 22, 2021

 Health Policy

these differences have widened since 2011.17 The impact for by levels of deprivation.21 This analysis also showed
of the COVID-19 pandemic on life expectancy is yet to be that, even though all the regions of England are subject to
established, but the combination of excess mortality broadly similar underlying health policies, regulations,
directly attributable to the acute effects of the virus, and laws, and all are served by the NHS, outcomes such
emerging evidence of long-lasting health problems as life expectancy and years lived with a disability in the
caused by the virus,18 and delayed diagnosis of many more prosperous regions of the UK are similar to those in
conditions such as cancer caused by the postponement the best performing advanced high-income countries,
of screening and reduced access to health-care services19 such as Sweden and Australia. By contrast, in the less
will probably lead to a sustained reduction in life prosperous regions of the UK, these outcomes lag behind
expectancy in many countries. The knock-on effects on the worst-performing advanced high-income countries,
the economy, particularly those that exacerbate existing such as Denmark and Greece.21 Similarly, disability-free
inequalities, will also have longer-term indirect effects. life expectancy varies substantially within each UK nation,
As the UK has had one of the highest death rates the consequence being that, in many parts of the UK, the
attributable to the COVID-19 pandemic so far, the gap in average person cannot expect to reach the statutory
life expectancy between the UK and other developed retirement age in good health.22 There are also inequalities
nations might grow in the coming years. between ethnic groups, with estimates suggesting that
There are also large differences between the four UK differences in disability-free life expectancy, at 11·5 years,
nations (appendix p 1). All have experienced a recent are twice as large as differences in life expectancy.23 See Online for appendix
slowing of the rate of increase in life expectancy at birth. Chinese men and women have the highest disability-
Life expectancy has consistently been higher in England free life expectancy at birth, whereas Bangladeshi men
than in the other three nations, with Scotland lagging far and Pakistani women have the lowest. The COVID-19
behind. Between 1998 and 2018, the gain in life expectancy pandemic has exacerbated these health inequalities,
at birth has been much smaller for women than for men. particularly for Black and minority ethnic groups who
For example, in England, life expectancy increased by have experienced persistently elevated mortality rates
4·3 years for men but only by 3·1 years for women. In from COVID-19.24 Differential exposure to SARS-CoV-2
Scotland, the gap was even greater, at 4·2 years for men influenced by occupation and housing conditions,
and 2·7 years for women. For both sexes, these gains differential severity of COVID-19 influenced by existing
were among the smallest in industrialised countries. health conditions, and differential interactions with the
This discrepancy is driven, to a considerable extent, by health service have all been suggested as potential
stagnating or falling life expectancy among women aged contributing factors.25,26
75 years and older, who have been affected especially The scale and nature of these differences point to the
harshly by austerity policies.20 importance of influences outside the health-care system
Life expectancy is, of course, derived from data on on health outcomes.22 The Dahlgren and Whitehead
deaths. It can be combined with data on people still alive model highlights the potential effect of the wider social
to generate measures of disability-free life expectancy determinants of health, such as housing, sanitation,
(DFLE) and healthy life expectancy (HLE). DFLE is an unemployment, education, and food production.27 Austerity
estimate of the number of years lived without a long- measures adopted since 2010 have had a disproportionate
lasting physical or mental health condition that restricts impact on the poor,28 creating insecurity of income,
daily activities. HLE is an estimate of the number of employment, housing,29 and even food supply, as revealed
years lived in very good or good general health, based on by the growth of food banks.30 Addressing these social
how individuals perceive their general health. England determinants of ill health will require wide-ranging actions
has the highest life expectancy for both women (83·1) across many sectors and at every stage of the human
and men (79·6), and Scotland has the lowest life life course, while recognising that disadvantage can be
expectancy for both women (81·1) and men (77·0). passed down generations, risking a downward spiral.31
England has the highest HLE and DFLE for both women These actions must account for intersectionality, whereby
(HLE 63·8, DFLE 62·2) and men (63·4, 63·1), whereas some individuals have a combination of characteristics
Wales has the lowest DFLE for women (59·5) and (all of which disadvantage them), and the existence of a
men (59·9), the lowest HLE for women (62·0), and health gradient between rich and poor. These considerations
second-lowest HLE for men (61·4; appendix p 2). point to the need for what is termed proportionate
Within the four nations of the UK, there is especially universalism,22 in which provision of services is universal,
poor health among populations in areas that have gone but measures are taken to increase uptake by those in
through deindustrialisation since the 1980s, such as the most need.
west of Scotland, parts of Northern Ireland, south Wales,
and the northeast and northwest of England. Analysis Mental health
by geography and deprivation shows that, although life The burden of disease attributable to mental illness,
expectancy varies by as much as 6 years between the including what are termed common mental illnesses
regions of England, most of the difference is accounted (ie, anxiety, depression, panic disorder, phobias, and

[Link] Vol 397 May 22, 2021 1981

 Health Policy

obsessive-compulsive disorder), has been growing over them reported self-harming behaviour or suicide attempts.
the past 25 years.32 The COVID-19 pandemic has also Universities have reported a huge increase in pressure on
had a profound impact on mental health, with many student mental health services and rising numbers of
individuals suffering from anxiety, isolation, and student suicides,47 and research shows an increase in
difficulties in accessing mental health support.33 High- adolescent girls presenting to UK Accident and Emergency
quality data are needed to understand this effect, departments with self-harm.48
particularly for susceptible groups, such as older The reasons for the increasing burden of mental
people, young people, people with pre-existing mental illness in young people are complex. Social media, the
health issues, and health-care workers.34 To mitigate impending threat of environmental catastrophe and
against long-term consequences for mental health, political instability, uncertainty about future prospects,
supportive measures are needed, such as providing higher rates of family breakdown, and academic pressure
widespread access to emer­gency psychological support have all been proposed as causative factors. Unrealistic
and increased investment in mental health services.35 social pressure to excel in all areas of life, promoted by
The mental health impacts of the COVID-19 pandemic social media and an ethos of consumerism, is another
have important implications for health inequalities and toxic, relatively new phenomenon. However, it is crucial
the wider economy. Mental illness is more common in to try to address this area of growing need as it is well
socioeconomically deprived populations36 and is the established that around half of mental illnesses start
leading cause of lost days of work in the UK; mental before the age of 14 years and three-quarters are
ill-health at work is estimated to cost the UK economy established by the age of 24 years,49 particularly because
between £74 billion and £99 billion per year,37,38 with adolescence and young adulthood are pivotal life stages
important consequences for the labour-intensive health for key decisions regarding education, employment, and
sector. relationships.
The mental health needs of the older population are The burden of disease due to alcohol and illicit drug
substantial. Although the age-specific prevalence of use has increased across the UK in recent years.
dementia appears to be decreasing slightly,39 population Alcohol-related deaths in the UK increased to an age-
ageing means that the absolute number of older adults standardised rate of 12·2 per 100 000 people in 2017,
experiencing cognitive decline due to Alzheimer’s which is similar to 2008 when alcohol-related deaths
disease or other types of dementia will rise;40 prevalence were at the highest recorded levels.50 Scotland consistently
of dementia increases from 2% for people aged has the highest rate of alcohol-related deaths in the UK,
65–69 years to 18% for those aged 85–89 years.13 However, at 20·5 per 100 000 in 2017, although this number has
older people’s mental health needs do not just relate to substantially reduced from a peak of 28·5 per 100 000
dementia. Depression is the most common mental in 2006.50 Drug-related deaths in England and Wales
health disorder in this age group, with an estimated have increased from an age-standardised rate of 42·9
prevalence of 22% in men and 28% in women aged per 1 000 000 in 1993 to 66·1 per 1 000 000 in 2017.51 In
65 years and older and more than 40% in people living in comparison, Scotland’s incidence of drug-related deaths
care homes.41 There is also a high prevalence of anxiety is more than three times the rate in England and Wales,
disorder.42 Other disorders, such as bipolar disorder and at 192·6 per 1 000 000 in 2017,52 and is the highest
psychosis, are less common but nonetheless significant. drug-related death rate recorded in the EU. There are
Research shows that older adults with depression are also substantial inequalities in alcohol-related and drug-
significantly less likely to be diagnosed and treated than related deaths across the UK. For example, more than
younger adults with the condition,43 and services and half of the drug-related deaths in Scotland occur among
funding for mental health care for older people is people from the most deprived quintile,53 and the rate
For data on the distribution of generally considered less of a priority than it is for of alcohol-related deaths is more than three times
alcohol-related deaths in working-age adults.44 higher in the most deprived quintile than in the least
the UK see [Link]
There is growing evidence of a high burden of mental deprived quintile in England. These increases in
[Link]/peoplepopulation
andcommunity/healthand illness among British children and adolescents, to the alcohol-related and drug-related deaths have occurred
socialcare/causesofdeath/ point that the situation has been described as a crisis.45 during a period when drug and alcohol services are
datasets/alcoholspecific Data from 2017 in England showed that one in eight under intense financial pressure. For example, in
deathsintheunitedkingdom
individuals aged between 5 and 19 years had at least one England, local authorities cut budgets by 18% in real
supplementarydatatables
mental illness and that one in twenty met criteria for two terms between 2013–14 and 2017–18,54 which contributed
or more mental illnesses.46 The same data show a gradual to an 11% reduction in people accessing treatment over
increase in mental illness in young people since 1999, the same period.
with the prevalence increasing with age, particularly on
transition to adolescence and secondary school.46 Of Maternal and child health
particular concern is the high level of mental illness in Maternal mortality in the UK is higher than it is in many
girls aged 17–19 years. Nearly one in four in this group countries in central and northern Europe (appendix p 3).
have a diagnosable mental illness, and more than half of Within the UK, there are substantial inequalities in

1982 [Link] Vol 397 May 22, 2021

 Health Policy

maternal mortality between different ethnic groups and 7

between groups with different levels of deprivation.55 The
6
maternal mortality rate in women from a Black ethnic

Deaths per 1000 livebirths

background is five times higher than that in White 5
women, while the rate in women from an Asian ethnic 4
background is double that in White women. Between the
3
most and least deprived groups, there is a doubling in
maternal mortality. Rather than narrowing, these trends 2
have been widening over the past decade.55 1
The UK’s high mortality from conditions such as
0
asthma, epilepsy, pneumonia, and meningococcal

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care, with infant mortality lagging behind many other Figure 2: Infant mortality in the UK and comparable high-income countries
high-income countries (figure 2).58 A recent, extremely Data are from 2018 or the latest year available. Source: Organisation for Economic Co-operation and Development.
detailed comparison with Sweden found that newborn
babies in the UK had many more problems at birth overall oral health in both children and adults has
than their counterparts in Sweden did, many of which improved greatly.66 The increased retention of natural
could be traced to their worse socioeconomic status.59 teeth is a positive change but, as individuals age and
Influences on health outcomes start in utero, and there is become more frail, complex and costly dental treatment
a clear social gradient in the extent to which children can is often required. Stark socioeconomic and geographical
access positive experiences in their early years.22 As inequalities in oral health exist. Steep and persistent
already mentioned, since 2010, the UK government has social gradients are found for oral conditions in both
chosen to implement prolonged austerity policies, children and adults, and oral health is worse in Northern
including reductions in entitlements to welfare provision, Ireland and Scotland than it is in Wales and England.67
with measures that have impacted particularly on Oral diseases are caused by the broader social
the most vulnerable.60 Concerns have been expressed determinants in society and shared risk factors, such as
about the substantial increase in suicide rates among consumption of sugars, tobacco, and alcohol.
adolescents in England and Wales since 2010.61 Child In the UK, dental services are organised and funded
poverty in the UK, as of 2017–18, was 30% and has been in a different manner than medical services are. The
increasing since 2013–14, when it was 27%.62 This poverty vast majority of the 40 000 dentists in the UK work in
rate is predicted to rise over the next few years, and primary care, providing general dental services to the
children in single-parent families, with three or more population. Across the UK, different payment systems
siblings, in households where no one is in work, or in exist but co-payments operate in all countries, according
rented or social housing are known to be at particular to which adult patients contribute to the costs of their
risk of poverty.63 dental treatment. Children and exempt adults do not
pay for their dental care. Patterns of dental attendance
Oral health are strongly influenced by socioeconomic status, and
Oral diseases (eg, dental decay, periodontal [gum] concerns over the cost of treatment are a major barrier
diseases, and oral cancers) are highly prevalent chronic to accessing dental services.68
conditions that have a considerable impact on quality of
life and are costly to health-care systems. The Global Multimorbidity
Burden of Disease study has highlighted that dental Older people are, individually, more likely to be healthy
decay in adults is the most prevalent chronic health than they were in the past. However, the absolute
condition globally—overall, it is estimated that 3·5 billion numbers with ill health are increasing. Many will remain
people are affected by dental diseases.64 A 2019 analysis healthy by virtue of being treated for hypertension or
shows that the treatment of dental diseases among EU diabetes, which averts the sequelae of these conditions.
countries costs in excess of €90 billion per year, the third Others, although not in perfect health, experience
most expensive condition behind diabetes (€119 billion) considerable alleviation of their symptoms. The corollary
and cardiovascular diseases (€111 billion).65 In recent of this and of earlier detection of chronic diseases and
decades, there has been a striking change in oral diseases their risk factors is that ever more people experience
among the UK population. When the NHS was first multimorbidity, requiring some health care for multiple
created, the state of oral health in the UK was appalling, disorders, even if they are only reviewed in primary care
with the complete removal of all teeth (edentulism) a every few months.36 Research in the UK estimates that
relatively common occurrence for even young adults, around 23% of the population meet current criteria for
often taking place before marriage. Nowadays, fewer multimorbidity, a figure that increases with age and
than 5% of adults in the UK have no natural teeth, and attention to early diagnosis—around two-thirds of people

[Link] Vol 397 May 22, 2021 1983

 Health Policy

30
others (despite growth in specialist posts in recent years),
Aged >65 years
Aged >80 years is that it might be difficult to obtain specialist expertise
25 when needed. Unfortunately, the accessibility of primary
Percent of the population (%)

20
care is now being threatened, with insufficient historical
investment in these services. To compound the problem,
15 chronic staffing shortages coupled with administrative
overload add to falling morale and cause physical and
10
psychological burnout. Such outcomes lead to growing
5 problems in recruiting and retaining general practitioners
and community nurses.
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The changing health needs of the population
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The UK’s ageing population

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Some changes in future health profiles can be predicted

Figure 3: Percentage of population at older ages in selected high-income countries, 2018
Source: Organisation for Economic Co-operation and Development. with relative certainty, such as the ageing of the
population and, to some extent, a relative fall in those
25
aged 18–65 years, albeit with caveats about future
Aged >65 years
Aged >80 years migration.70 Forecasting with some confidence is possible
when the association between risks and disease are
20 known and have long time periods, as is the case with
Percent of the population (%)

smoking. Such forecasting is more difficult when lags

15 between exposure and outcome are short, as with many
of the consequences of hazardous drinking, and where
public policies can have a major impact in the short term.
10
Although the UK does not have a particularly high
proportion of older people relative to other high-income
5 countries, with the share of people older than 65 years
and people older than 80 years falling from 4th to 12th
For data on the older 0 between 1995 and 2016 in one comparison of 17 countries
population in different (figure 3), it will eventually face similar challenges as
nI n

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countries see [Link]

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other countries. Ageing per se does not necessarily affect

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health-care utilisation or add pressure to constrained

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NHS resources unless it is associated with increased

rk

chronic illness and higher rates of multiple long-term

Yo

Figure 4: Percentage of population aged 65+ years and 85+ years, 2019 conditions.71
Source: Office for National Statistics.72 Considerable variation exists within the UK, with the
largest share of older and very old people in the southwest
older than 65 years meet these criteria, with nearly half of England and the smallest share in the northeast of
having three or more conditions.36 There have been England (figure 4). There is also a sizable discrepancy
several attempts to classify commonly occurring clusters in the age distribution of different ethnic groups
of conditions. Some diseases frequently co-exist and (appendix p 3). Both the geographical and ethnic spread
share common causes, but there is also considerable of the older population matters, as it leads to specific
heterogeneity, and illnesses can also be completely pressure points on NHS access, as well as contributing to
unrelated. Chronic physical conditions often co-exist with the unequal distribution of ill-health within the UK. As
mental health disorders—particularly with dementia— ethnicity is not recorded on death certificates in the UK,
with evidence that the relationship is bidirectional.69 it is not possible to routinely report on life expectancy
There is a clear association between multimorbidity and stratified by ethnicity. However, some recent studies that
socioeconomic deprivation, and people living in deprived have used various techniques to try to estimate life
areas are likely to develop multimorbidity 10–15 years expectancy by ethnicity show significant discrepancies
earlier than those living in more affluent areas.36 between groups, which vary by region.73–75
Multimorbidity has profound implications for how
health care is delivered, as it demands a holistic approach The working population
delivered by multidisciplinary teams. The model of The participation of women in the labour force is at an
primary care, with its generalist approach, has found it all-time high.76 Thus, as the share of the population who
easier to respond to this challenge than some models are of working age declines, there is little scope to draw
used in other countries, but the disadvantage, in a country even more into the workforce, an important considera­
that has somewhat fewer medical specialists than many tion given their major contribution to the health and

1984 [Link] Vol 397 May 22, 2021

 Health Policy

care workforce. However, caution is needed. Old-age

Drug use disorders
dependency ratio, a frequently cited measure, has been Diabetes
used in sometimes apocalyptic predictions, typically to Falls
argue for the unsustainability of the welfare state. Yet it Chronic obstructive pulmonary disease
Alzheimer's disease and other dementias
assumes an economically (and socially) inactive stage of
Osteoarthritis
life beyond 65 years of age that is no longer the case. The Other musculoskeletal disorders
raising of the retirement age in the UK and many other Endocrine, metabolic, blood, and immune disorders
countries has changed such calculations considerably, Anxiety disorders
Tracheal, bronchus, and lung cancer
even before taking into account the work and informal
Low back pain
care of spouses, parents, adult children, and grand­ Neck pain
children provided by older people, sometimes with Headache disorders
competing demands.77,78 There are, however, many Oral disorders
Age-related and other hearing loss
uncertainties about the future composition of the UK Depressive disorders
population. The experience of Japan,79 a country that has Gynaecological diseases
had very little immigration albeit for different reasons, is Ovarian cancer
concerning, as the young are attracted to major centres for Colon and rectum cancer
Lower respiratory infections
their early working careers, while older people remain in Breast cancer
rural or coastal regions, creating a skill gap for care. Asthma
In this context, the UK Government’s stated goal of Neonatal disorders
reducing migration from the hundreds of thousands to Stroke
Ischaemic heart disease
the tens of thousands is a clear cause for concern. The
–80 –60 –40 –20 0 20 40 60 80 100
NHS has a long history of relying on foreign recruit­
Percent change in burden (%)
ment in response to workforce shortfalls. For example, in
light of ongoing uncertainty about future EU citizen Figure 5: Percentage change in burden due to the top 25 causes of DALYs in women in the UK, 1990–2019
arrangements, there has been a 90% reduction in Source: Global Burden of Disease. DALY=disability-adjusted life-year.
nurses from other EU member states joining the UK’s
register in 2017–18 compared with 2016–17.80 Growing Cirrhosis and other chronic liver diseases
Drug use disorders
numbers of medical posts remain unfilled, with the
Diabetes
government refusing visas to non-EU doctors with job Alzheimer's disease and other dementias
offers and even to those training in this country.81 The Alcohol use disorders
social care sector is also heavily dependent on foreign Oesophageal cancer
Osteoarthritis
recruitment, yet senior care workers are currently not on Falls
the government’s so-called shortage occupation list.82 Other musculoskeletal disorders
Endocrine, metabolic, blood, and immune disorders
Changing burden of disease Prostate cancer
Age-related and other hearing loss
The combination of trends in underlying population Headache disorders
health, the application of effective preventive inter­ Neck pain
ventions, and advances in health care have led to a shift Low back pain
in the predominant share of the burden of ill-health Chronic obstructive pulmonary disease
Depressive disorders
worldwide from conditions causing premature mortality Colon and rectum cancer
to conditions that cause disability. Health systems Lower respiratory infections
everywhere must adapt to the changing nature of health Self-harm
need. The Global Burden of Disease study captures this Tracheal, bronchus, and lung cancer
Stroke
idea in its analysis of disability-adjusted life-years Neonatal disorders
(DALYs). Figures 5 and 6 show the percentage change in Road injuries
burden attributed to the top 25 causes of DALYs in the Ischaemic heart disease
UK for both genders from 1990 to 2019. For both men –80 –60 –40 –20 0 20 40 60 80 100 120 140
and women, there have been substantial increases in Percent change in burden (%)

disease burden due to drug use disorders. In men, these Figure 6: Percentage change in burden due to the top 25 causes of DALYs in men in the UK, 1990–2019
addiction problems have been exacerbated further by Source: Global Burden of Disease. DALY=disability-adjusted life-year.
increases in disease burden due to alcohol use disorders.
Addiction services have struggled to meet this rising risk of many smoking-related diseases such as stroke and For data from the Global
demand in the context of ongoing funding cuts over the myocardial infarctions, which have been declining for Burden of Disease see
[Link]
past decade.83 This situation has had implications for several decades. However, the benefits of this change are results-tool
NHS services, as harmful drinking has contributed to yet to be felt, with increases in disease burden due to
the increase in disease burden due to liver cirrhosis. chronic obstructive pulmonary disease seen in both men
Smoking rates have fallen markedly, reducing the future and women. Conversely, rates of obesity at younger ages

[Link] Vol 397 May 22, 2021 1985

 Health Policy

are increasing, with implications for a range of common marketing. Examples include minimum alcohol pricing
disorders, such as diabetes, cancer, and dementia. in Scotland and Wales, above-inflation increases in
The proportion of the population aged 65 years and tobacco taxation, a ban on smoking in public places, point-
older is predicted to increase from 18·5% in 2019 of-sale displays, the sugar tax, and standardised cigarette
to 23·9% in 2039.84 Assuming no change in age-specific packaging. However, these face powerful lobbying
utilisation, this would increase demand for health and activities by the corresponding industries, both directly
social care in particular.85 The changing population and through several think tanks that they fund.91,92 For a
structure has already led to an absolute increase in brief period, the alcohol and food industries benefitted
numbers of deaths, as predicted, after many years of from the creation of so-called responsibility deals, in
decline.86 A major component of health costs is driven by which the UK Government sought to engage with them
proximity to death, not by chronological age; many older in official forums. However, the government’s own
people are now healthier than their counterparts in evaluation found that industry representatives typically
previous generations. However, the absolute number of proposed the least effective measures and opposed those
older people with multiple conditions is set to increase known to be effective.93 These respon­sibility deals did lead
substantially over the next few decades, potentially more to pledges from many companies to reduce salt content in
so as the emphasis on early detection continues. As food and contributed to a reduction in overall salt intake
premature mortality reduces, disabling conditions whose in the UK of 11% between 2006 and 2014.94 However,
prevalence increases sharply with age (eg, sensory eventually, key health advocacy organisations withdrew.
deficits, mobility problems, cognitive decline, and incon­ Moving forward, there is a need for more joint
tinence) will progressively accrue, leading to complex approaches that bring together different groups working
multimorbidity. These trends in common conditions on, for example, tobacco, alcohol, or diet to secure maxi­
have been brought together with population ageing in a mum benefit from shifting population norms on the five
dynamic model.85 This model predicts that the number healthy living imperatives (not smoking, adhering to
of people with four or more conditions will increase alcohol guidelines, maintaining a healthy weight, staying
between 2015 and 2035 by 21% in those aged 65–74 years, physically active, and eating a healthy diet) that influence
130% in those aged 75–84 years, and 470% in those aged rates of non-communicable diseases. This strategy will
85 years and older. The changing nature of demand for require policies that address these issues specifically and
health and social care that results is a challenge for any others that take a concerted approach to the upstream
health system and requires an explicit response, even determinants of health, including both the well recognised
more so for a health-care system that encourages people social determinants of health and, even more now, the
to seek earlier medical care for conditions, sometimes commercial determinants,95 by looking at how powerful
before they are clinically manifest. Therefore, the concern vested interests can subvert health policies. It is also
is less ageing per se, but ageing with multiple preventable necessary to address the political determinants of health,
conditions leading to poor health and wellbeing. such as austerity, welfare, and immigration regimes, and
the environmental determinants, such as the design of
Reducing the need for health care health-promoting cities.
The need for a preventive focus
One of the key messages of the Tallinn Charter8 was that Addressing the social determinants of health
effective prevention could reduce the need for health Although successive governments have adopted effective
care and thus the need for scarce resources. Effective public health policies, these have struggled in the face
prevention was also a key message of the Wanless Report, of wider societal problems. Consequently, despite noted
commissioned by the UK Treasury,87 which forecast the successes in areas such as tobacco control, the UK ranked
potential to moderate future NHS expenditure if what it only 12th overall in an assessment of public health policies
called a fully engaged policy could be adopted. This across the European region of WHO.96 Looking ahead,
concept, of investing in health improvement to reduce there is clearly a need to address the underlying social
future costs, also features prominently in the NHS determinants of health, or the conditions in which people
Long-Term Plan.88 An additional consideration is the are born, grow, live, work, and age,22 with policies that
compelling evidence linking better health to economic address precariousness of employment, income, housing,
growth through higher labour force participation and and food security.97 The UK has high rates of child poverty,
productivity.89 There are many examples of successes in lax building standards, and underinvestment in social
implementing health-promoting policies in Europe.90 housing, contributing to many people living in substandard
The countries of the UK have been among the leaders accommodation and, since 2010, a marked rise in food
internationally in many of the most effective policies insecurity.30 Other social problems relate to the employment
to reduce harms associated with use of hazardous market: although the introduction of a minimum wage was
substances, such as tobacco, alcohol, and, most recently, associated with a demonstrable improvement in mental
junk food. Governments have recognised that the most health,98 and official unemployment rates are low, there
effective policies are those based on price, availability, and are growing numbers of people who remain below the

1986 [Link] Vol 397 May 22, 2021

 Health Policy

minimum wage, a practice that is illegal but rarely policed.99 world-leading clinical trial programme, and the rapid
Growing numbers of people also face severe uncertainty vaccination of the population triaged by risk factors
about income and employment in what is termed the gig such as age and comorbodities.106 Impacts in parts of the
economy, charac­terised by piecework and limited employ­ social care sector, especially in care homes, have been
ment rights. Against this background of the erosion of devastating and responses by staff similarly exceptional,
wider welfare policies and falling public expenditure in again with many lessons to be learnt.107
other areas of welfare, the NHS is increasingly left as the The UK’s response has, however, come at an enormous
one remaining pillar of the UK welfare state. cost, both financially and in terms of the long-term
Health care is an important route through which health consequences for health. These consequences can be
improvements can be channelled, but other sectors considered under five headings: the long-term conse­
remain important in addressing health promotion and quences of the infection on the body; delays in care as a
inequalities. There is compelling evidence in many areas consequence of the suspension of certain NHS services;
that health-promoting policies work, especially those that the health effects of the lockdown; the impact on NHS
involve all relevant sectors, enshrined in the concept of staff; and the long-term economic impact. In the
Health in All Policies. Wales is pioneering this approach first category, it is becoming clear that many of those who
through the Wellbeing of Future Generations Act 2015 survive COVID-19 have persisting health problems, many
and the Public Health Act 2017.100,101 As a major employer, apparently associated with the action of the virus on
this is an area where the NHS could play a crucial role, the vascular endothelium and the associated immune
although such an approach would require a substantial response and hypercoagulability.108 In this respect, some
culture change in an organisation that is more often have questioned whether it will come to be compared
associated with high levels of work-related stress and with polio, which also left a long-lasting legacy of ill-
burnout. Health-promoting policies do have the potential health. In the second category, there was a large reduction
not only to alleviate suffering but also to reduce further in primary care attendances,109 storing up considerable
the demand on the NHS if there is the political will to unmet need for the future, and routine surgery has been
implement them. suspended, leaving a massive backlog to be treated in
what was an already struggling system. Delayed diagnosis
Immediate threats to the NHS and treatment of early-stage cancer has been estimated to
The need for a resilient NHS lead to more than 6000 additional deaths in a year.110
The initial version of this paper argued that the NHS must Estimates suggest that 3800 early cancers that would have
prepare for the unexpected and ensure it was resilient in been picked up on screening have been missed.111 In the
the face of potential threats, including a pandemic,102 third category, prolonged isolation coupled with the
especially given the threat posed by the loss of links with cessation of specialist services is likely to contribute to an
European agencies such as the European Centre for increased burden of mental illness, while the closure of
Disease Prevention and Control and the European schools is likely to contribute to mental illness in children
Monitoring Centre for Drugs and Drug Addiction.103,104 The and young people.6 The fourth category includes the
COVID-19 pandemic has, tragically, revealed that the UK effects of psychological trauma on NHS and social care
was less prepared than it could have been. staff, including responses more usually seen in survivors
As of April, 2021, the UK was among the worst affected of armed conflict.112 Fifth, the pandemic is expected to
countries in the world, measured by deaths attributed lead to a long-term reduction in economic growth,113 that
directly to COVID-19 or by excess all-cause mortality (the could see many of the health problems associated with
preferred measure for international comparisons). austerity in the period after 2010 return.97 To add to the
There will be many lessons to learn from the response: problems, the ability of the NHS to respond could be
confused messaging by ministers; outsourcing of complicated by the need for new ways of working,
essential functions to companies lacking expertise; including greater use of personal protective equipment,
fragmentation of the NHS and public health and social social distancing, and remote consultations.
care systems; elevated mortality rates among Black and There are also other threats ahead, some more certain
minority ethnic groups; fraught relationships between than others. One is antimicrobial resistance, an area
central and local government, as well as with devolved where the UK has shown global leadership.114 Another
nations; serious failures in the procurement of essential is the consequences of a generation transitioning into
items, from ventilators to test kits and personal retirement in a much more precarious financial state
protective equipment; and entire new but largely unused than their parents because of closure or reduction of
hospital facilities.105 The response and efforts of those pension schemes and lower levels of home ownership;
working in the NHS should also be recognised as this generation might struggle to come to terms with
exceptional, including repurposing existing hospital their straitened circumstances.90 A third is climate
facilities, rapidly expanding access to teleconsultations, change, with evidence that the climate is changing even
reallocating staff, sharing knowledge about the emerging faster than predicted, potentially nearing a tipping point
clinical characteristics of this disease, implementing a of runaway global warming. The COVID-19 pandemic

[Link] Vol 397 May 22, 2021 1987

 Health Policy

has ushered in a temporary period of reduced carbon services will be the nature of any future international
emissions; government actions and economic incentives trade agreements. Issues around intellectual property
after the pandemic will determine whether carbon rights, technical barriers to trade, and investor protection
emissions continue on the same path.115 need to be thought through carefully,119 and protections
In summary, the future is uncertain. Some of the for health and health care put in place. It is vitally
uncertainties can be anticipated to some extent but for important that, in the new trade agreements, health is
others, it is more difficult. The lesson from the COVID-19 not subverted by commercial interests for economic
pandemic is that the NHS must both anticipate predictable gain.120 Overall economic performance following depar­
developments and build in sufficient resilience for the ture from the EU will also be very important, with
unexpected while working with other sectors to develop implications not just for the available funds to spend on
holistic solutions. health, but for the wellbeing of the UK population and
the consequent demand for health care.
Leaving the EU
The UK’s decision to leave the EU will have serious Conclusion
consequences for health116 but, as of April, 2021, these This Health Policy paper has reviewed the current health
consequences have yet to become fully apparent. Although of the UK population and the changing health needs and
imports to Great Britain have fallen substan­tially, the full has considered what future challenges lie ahead. From
effect of leaving the EU will not be visible until the these considerations, we can draw several conclusions.
UK Government introduces the full range of customs First, despite substantial improvements in life expec­
checks it is required to impose but has, for now, delayed. In tancy, many physical and mental health outcomes are
addition, it is difficult to distinguish the economic effects of suboptimal relative to other high-income countries.
leaving the EU from those of the pandemic. The problems Driving this suboptimality is that, across all ages but
ahead can, however, be understood from the near collapse especially in childhood and old age, the population has
of some exports, such as foodstuffs, since the EU has high levels of preventable ill-health, which is unfairly
already imposed checks on its side of the border. The distributed across society. As the UK has experienced a
problems are also clear from the issues faced by shops in relatively high excess mortality rate attributable to
Northern Ireland, no longer able to depend on their COVID-19, the gap in life expectancy between the UK
historical supply arrangements with Great Britain. It has and other developed countries is likely to grow.
also become apparent that many commitments made by Second, in the future, there will be relatively fewer
the UK Government before leaving the EU, many of them people in the working population, especially if current
suggesting that particular arrangements will continue as policies on migration continue, and a sharp rise in people
before, have not in fact been honoured, either in part or in with complex multimorbidity. This trajectory will create a
whole. While UK scientists will continue to be able to mismatch between needs and capacity to address those
participate in some, but not all, of the EU’s research needs, both through workforce availability and securing
programmes, the Turing scheme is substantially inferior to the economic basis for sustainable funding. To address
the ERASMUS+ scheme that it relaces, in terms of mobility these issues, there needs to be an increased focus on
of staff and students. A Global Health Insurance Card, to prevention and health promotion that takes a multisectoral
replace the European equivalent, no longer includes the approach to the social, political, and commercial causes of
non-EU European Economic Area countries. Some poor health. The crucial role the NHS can play by setting
arrangements for data sharing during emergencies with an example as a healthy employer, reducing risk factors
the European Centre for Disease Prevention and Control for chronic diseases, promoting healthy ageing, enhancing
have been agreed but, again, are much inferior to those that confidence, and promoting social engagement should be
existed previously. Further progress is complicated by addressed explicitly. However, the NHS is increasingly
the loss of trust in the UK among many politicians in the operating in an environment in which other sectors—
EU27, given the UK’s failure to implement measures it had especially social care—are being eroded in terms of
previously committed to, especially in relation to the expenditure and general infrastructure, instead of being
Northern Ireland Protocol. This situation has not been maintained as supportive systems.
helped by the nationalist rhetoric that has accompanied Finally, there are many immediate threats that will
AstraZeneca’s failure to deliver to EU countries the quantity affect the health of the population and service provision.
of vaccines that it had committed to.117 Crucially, the UK will need to develop strategies to
Beyond the immediate problems, the health of the mitigate against the wider and long-term consequences
UK population is affected by many other aspects of for health of the COVID-19 pandemic. In addition,
public policy. Food quality and safety, agriculture, land the UK’s departure from the EU, growing antimicrobial
management, and environmental regulations are just a resistance, and increasing climate change are all major
few of the areas of concern currently addressed by EU challenges with significant consequences for the NHS.
legislation that have substantial implications for human Other unforeseen risks, such as economic downturn or
health.118 Of particular concern to health and health even conflict, would impact the NHS but are practically

1988 [Link] Vol 397 May 22, 2021

 Health Policy

difficult to plan for. Instead, the focus should be on 17 Marshall L, Finch D, Cairncross L, Bibby J. Mortality and life
building a resilient and preventive health-care service, expectancy trends in the UK: stalling progress. November, 2019.
[Link]
so that the NHS is better prepared for any future expectancy-trends-in-the-uk (accessed Nov 17, 2020).
challenges. 18 Roberts CM, Levi M, McKee M, Schilling R, Lim WS, Grocott MPW.
COVID-19: a complex multisystem disorder. Br J Anaesth 2020;
Contributors 125: 238–42.
MM and KD led the working group that prepared the paper. MA and
19 Richards M, Anderson M, Carter P, Ebert BL, Mossialos E. The impact
CJ-W managed the processes of the working group, compiled the data and of the COVID-19 pandemic on cancer care. Nat Cancer 2020; 1: 565–67.
figures, and contributed to editing of the manuscript. All other authors
20 Hiam L, Dorling D, Harrison D, McKee M. Why has mortality in
provided critical input into the drafting and editing of the manuscript. England and Wales been increasing? An iterative demographic
Declaration of interests analysis. J R Soc Med 2017; 110: 153–62.
We declare no competing interests. 21 Newton JN, Briggs ADM, Murray CJL, et al. Changes in health in
England, with analysis by English regions and areas of deprivation,
Acknowledgments 1990–2013: a systematic analysis for the Global Burden of Disease
Funding for the LSE–Lancet Commission on the future of the NHS was Study 2013. Lancet 2015; 386: 2257–74.
granted by the LSE Knowledge and Exchange Impact (KEI) fund, which 22 Marmot M, Goldblatt P, Allen J, et al. The Marmot Review:
was created using funds from the Higher Education Innovation Fund fair society, healthy lives. February, 2010. [Link]
(HEIF). The funder of the study had no role in study design, data [Link]/resources-reports/fair-society-healthy-lives-the-marmot-
collection, data analysis, data interpretation, or writing of the report. review (accessed Nov 17, 2020).
23 Wohland P, Rees P, Nazroo J, Jagger C. Inequalities in healthy life
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